Provider Demographics
NPI:1801095765
Name:GOLA, GWEN R (PT)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:R
Last Name:GOLA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:R
Other - Last Name:PESIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:205 W WACKER DR
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1216
Mailing Address - Country:US
Mailing Address - Phone:312-640-0329
Mailing Address - Fax:
Practice Address - Street 1:19841 WOLF RD
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-1315
Practice Address - Country:US
Practice Address - Phone:708-479-0320
Practice Address - Fax:708-479-3695
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013181225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL568080OtherMEDICARE GROUP NUMBER
IL1619980OtherBCBS OF IL
IL568150OtherMEDICARE GROUP NUMBER
IL567700OtherMEDICARE GROUP NUMBER
IL1619980OtherBCBS OF IL
IL568150OtherMEDICARE GROUP NUMBER
ILR01575Medicare PIN